Most patients who come to us referred by other patients simply want to know if we can make their vision as good as their friends'. However, patients who find us through the Internet often come in armed with such questions as, "What kind of pupillometer are you using to measure my pupil size?

Are you using the Summit, VISX, Autonomous, Nidek, LaserSight or Technolas laser? Do you do an up-and-down flap or a nasal hinge? What is the optimal size of the ablation zone considering the size of my pupils?" One patient posted the following comment on a Web bulletin board: "There is so much information out there about laser-assisted in situ keratomileusis (LASIK) that if you were crazy enough you would think you could perform this surgery."

The Web is also filled with misinformation about refractive surgery. Prospective patients who are researching the procedures and those who had surgery, especially those whose outcomes were less than optimal, are more than willing to share their experiences and readily dispense advice.

In counseling patients preoperatively and managing them postoperatively, I've found that knowing what information patients are exposed to on the Internet allows me to address issues proactively and support them with scientific data. Here's how it can help you.

Patients typically post questions and concerns on "bulletin boards." A bulletin board usually has an advice panel of doctors who answer the questions. Other patients, prospective patients, technicians, counselors and refractive surgery coordinators often respond as well.

You can view bulletin boards on the following Web sites:

• www.asklasikdocs.com
• www.usaeyes.org
• www.chicagolasercenter.com (also listed as "LASIK Surgery Forum" on search engines).

Browsing these sites can give you insight into everything from how patients choose a surgeon to what they expect during a preoperative exam. In an attempt to select "the best surgeon," for example, patients often try to compare information other than just the surgeon's experience and outcomes. A recent post on a bulletin board read: "I'm considering three surgeons in my city. One surgeon uses Hansatome microkeratome with the superior hinge. One uses Chiron ACS microkeratome with the nasal hinge. And the third one uses Carriazo-Barraquer microkeratome. Which microkeratome is the best?"

In response to this post, another patient wrote: "My research has shown that Hansatome is the best microkeratome because it never jams. Also, it makes a superior hinge, which means that gravity and blinking keep the flap smooth and the risk of striae is eliminated. "

The surgeons on the advice panel recommended that the patient compare the experience and outcomes of each surgeon rather than focus on the equipment. In reading these comments it becomes clear that patients have in-depth knowledge of equipment, and that sometimes the information isn't based on scientific data. It may be helpful, therefore, to address equipment and other issues proactively, rather than have patients walk out of the office, search the Internet for answers and make their decisions based on the comments they find on the Web.

There has been a lot of exchange on the Internet about the cost of LASIK. Some patients comment positively on experiences they've had at low-cost centers. Many, however, post comments like this: "I had the 'cheap deal'-- and guess what? I received cheap service. Spend the extra money."

Another post issued the following warning: "Buyer beware. I went to a heavily advertised clinic that boasted a low price and quick service. Now I wish I had gone elsewhere. I needed an enhancement and the doctor refused to do it after promising that he would. I had to get it done elsewhere. I strongly urge you to stay away from 'bargain basement' clinics."

Such patient comments can be useful during a consultation when the price of the procedure comes up. In fact, we usually discuss price differences proactively with prospective patients.

Many patients on the Internet have sophisticated knowledge of the steps involved in the preoperative assessment.

One patient informed bulletin board participants on the steps involved in determining eye dominance. Another was concerned about pupil size measurement. "When I asked my doctor about my pupil size, he only said that I didn't appear to dilate too large. I am uncomfortable with this level of casualness on what I perceive as a critical parameter."

A patient commenting on the quality of his preoperative examination and the attentiveness of staff, wrote: "My preoperative examination was shoddy at best, i.e. no pupil measurement. Also, the counselors never returned my call. I am going to have my procedure done at another center where I got a thorough pre-op exam and the staff was very professional."

These comments indicate that patients pay careful attention to the steps of the pre-op exam. If they perceive an examination to be incomplete, they may seek out another surgeon.

Frank discussion of potential side effects backed with scientific data and specific answers to patients' questions may help you build trust and help patients feel confident in their choice of you as their surgeon.

Recent media reports have profiled at length potential side effects of LASIK, such as glare, halos, decreased contrast sensitivity and dry eyes. Internet discussion groups abound with questions and comments about these potential side effects. One patient wrote: "My doctor said that I may have some glare and starbursts after LASIK, but it will be no worse than what I experience now with my glasses. I feel he may be understating my risk for these problems. Should I get a second opinion?"

If you minimize the incidence and importance of side effects during the patient consultation, the patient may loose trust in you and go elsewhere.

Flap complications, such as striae, incomplete flaps, buttonholes, free caps, epithelial defects and diffuse lamellar keratitis (DLK) are discussed extensively on bulletin boards. Patients who complain bitterly are those who feel the surgeon minimized the importance of their complications.

One patient wrote: "I had a buttonhole flap. My surgeon told me, 'Don't worry, this is not a complication. I'll get you seeing well in no time.' Is a buttonhole flap a bigger deal than my doctor is letting on?"

Another patient wrote, "I had stage 3 Sands of Sahara, but my flaps were never lifted and irrigated. I have blurry vision now. I think my flaps should have been lifted. Every ophthalmic article I've read states that in stage 3, the flap should be lifted and irrigated copiously."

This exchange points out the importance of discussing complications with patients and presenting them with scientific evidence to support the course of management. Such discussions may reduce patients' need to seek second opinions on the Internet and protect them from misinformation.

On the Internet, patients can research procedures and equipment extensively. They can also express concerns that they may not feel comfortable expressing to their surgeon.

Some exchanges of data may be correct. But the conclusions drawn by non-professionals are often not. It's extremely useful, therefore, to view exchanges on the Web. We can identify patient concerns, address them proactively with patients and help them draw conclusions based on fact, not fiction.

Misinformation Alert

Here's what to consider about Internet advice.

By Glenn Hagele,Sacramento, Calif.

The desire to develop a balanced Internet resource to help refractive surgery candidates find a qualified surgeon was the spark that established the Council for Refractive Surgery Quality Assurance (CRSQA). We've sought to provide patients with information somewhere between the self-promotion of a doctor's Web site and the rhetoric of the anti-refractive folks we hear so much about these days. Our purpose is to provide accurate information in as unbiased a format as possible, then to let the patient decide.

An organization like ours is an example of the constructive power of the Internet. But the Internet has a darker side.

The power of a very small group of unidentified people -- even one person -- to greatly influence public opinion makes the Internet a very dangerous place for the uninformed. On Internet bulletin boards and newsgroups, your practice may be discussed without you ever knowing it.

Often, these bulletin boards aren't monitored to ensure appropriate content. Most inaccurate statements are misunderstandings in the realm of incorrectly reporting a doctor's enhancement policy or blaming a laser for a buttonhole flap. Sometimes, however, misinformation is a deliberate attempt to influence public opinion about you, your product or refractive surgery in general. Because of newsgroup archives and the ability of Internet surfers to search vast amounts of information with a few clicks, prospective patients may see inaccurate information for years to come.

In extreme cases, malicious individuals with an agenda can inundate a bulletin board with inaccurate and biased information. For example, Dave Edmiston, M.D., Sacramento, Calif., maintained a bulletin board at his eyeinfo.com site that became flooded with vulgarity and anti-refractive surgery rhetoric. The rate of the attacks was such that he chose to shut down the bulletin board rather than expend the resources necessary to keep it void of inappropriate information.

CRSQA representatives monitor all major bulletin boards and newsgroups. Mostly, we respond to patient questions and concerns, but occasionally we will discover an inaccurate or downright offensive statement. We're hardly self-proclaimed Internet police, but when appropriate, we respond with accurate information or let the targets of misinformation know of its presence and suggest that they respond.

You'll see other examples of misinformation and efforts to correct it. It's important for you to be aware of them if you're involved in refractive surgery. As I mentioned, the Internet has the power to influence public opinion about your abilities, even if you don't participate in Internet discussions. It may be valuable to ask an Internet expert to search for references to you, your practice or your products. You may be surprised by what you find.

Where Unhappy LASIK Patients Go

The director of a controversial Website explains his mission.

By Ron Link, New York, N.Y.

Surgical Eyes was created as an information base for those suffering with long-term complications from refractive surgery. Our goals are simply these:

• to raise awareness of the issues
• to identify lasting solutions
• to provide support for the post-refractive surgical failure.

Surgical Eyes has the potential, if given the chance, to serve as a viable and active conduit between vision care professionals and those who need their help.

The impact of Surgical Eyes is not yet fully realized. By shining the light on the very fact that a "20/20 underclass" (aptly coined by Dr. Leo Maguire) exists, and on those with more severe complications, we're on the way to achieving our first goal: acknowledgement of people with real quality of life compromises. Under our umbrella, statistics have names and hope for the future.

For the refractive surgery patient with long-term complications, our organization and Web site have proven to be an invaluable resource. Our bulletin board is populated by people with longer-term post-op concerns who share their knowledge of potential new technologies to correct visual problems.

Surgical Eyes went through considerable legal expense to arrive at rules of participation for the users of our bulletin board. Any postings with content that belongs in the private domain are simply not tolerated on our bulletin board.

Input by medical professionals is heartily encouraged. With your participation, we have the potential to be a true open forum on what does and doesn't work, or may work in the future.

Dialogue has already begun with many physicians who stand a chance of helping us achieve our common goals of better health for the individual and the practice of medicine as it ought to be.

Surgeons should tune into the site for a number of reasons, including:

• To better understand what patients are seeing post-op. Specifically, recognizing and making connections between post-op corneal conditions and diminished quality of vision.
• To understand how to create fewer patients with poor outcomes.
• To offer insight, hope and, ultimately, solutions for our visual futures.
• To better grasp the psychological manifestations of compromised vision often represented to patients as a clinical success.

Surgical Eyes presents surgeons with a rare opportunity to not only read about real-life complications but to go one step beyond and prevent them.

While Surgical Eyes does disseminate information about unsuccessful surgeries, our overriding goal is visual rehabilitation for the post-refractive patient with complications. As with most situations, the first step in solving a problem is to recognize that there is one.

Our focus is to facilitate the development of lasting solutions for our growing community. We encourage doctors to become part of the process. We won't achieve our goals any other way.